Pre-submission validation that catches claim rejections before they cost you money. Built for South African healthcare. Powered by AI.
Every rejected claim means delayed payment, increased admin burden, and cash flow pressure. For a practice processing 500 claims per month, that is R60,000-R80,000 in revenue sitting in limbo — every month.
SA mandates V/W/X/Y codes for all injury claims. This is the #1 rejection reason — practitioners remove them to simplify coding.
Using E11 instead of E11.9. Schemes require maximum specificity — 3-character codes are rejected when 4th/5th characters exist.
Prostate codes on female patients. Pregnancy codes on males. Perinatal codes on adults. Often just data entry errors.
Upload your claims CSV or Healthbridge EDI export. Auto-detects format, maps columns, and parses data. Supports standard CSV, TSV, and Healthbridge switching format.
13 core ICD-10 rules + 276 tariff codes + 7 scheme profiles + AI suggestions. Checks gender, age, specificity, external causes, unbundling, discipline, PMB eligibility, and more.
Auto-corrects high-confidence issues. Downloads corrected CSV. Saves results for trend tracking. Pattern learning gets smarter with every analysis.
Our fine-tuned medical coding models analyze flagged codes and suggest the correct ICD-10-ZA code with confidence levels and reasons. Dual-provider architecture ensures 99.9% availability.
High-confidence deterministic fixes applied automatically: non-specific codes get .9 appended, missing ECCs get X59 added, format typos (J069 → J06.9) are corrected. Medium-confidence fixes flagged for review.
Analyzes saved rejection history to identify recurring patterns. Predicts rejection probability for any code based on scheme + historical data. Gets more accurate with every analysis.
Compares your rejection rate to the network average. Identifies your worst-performing schemes and most common coding errors. Generates actionable recommendations with Rand impact estimates.
The Claims Intelligence Engine represents a breakthrough in South African healthcare technology. Built by Visio Research Labs, it is the first SA-built pre-submission validator with AI-powered coding assistance and scheme-specific rule intelligence.
No existing SA tool validates claims against ICD-10-ZA specificity rules, external cause code requirements, AND scheme-specific rules in a single pass. International tools (Optum, Waystar) use ICD-10-CM — the US variant — and don't know Discovery's KeyCare GP referral rules or GEMS' 28-day chronic supply limit.
The AI suggestion engine is prompted with SA medical coding expertise: ICD-10-ZA conventions, NHRPL tariff codes, CMS guidelines, PMB conditions, and dagger/asterisk rules. It doesn't just suggest any code — it suggests the right SA code with scheme-specific considerations.
Every analysis makes the system smarter. After 6 months of 88 Netcare clinics feeding real rejection data, the pattern engine will have a proprietary dataset no competitor can replicate. This is the real defensible advantage.
Auto-detects and parses Healthbridge claims switch EDI format. No CSV export needed — practices can validate directly from their existing workflow. 50+ BHF provider type codes mapped to discipline names for accurate cross-validation.
Access the Claims Intelligence Engine from your Netcare Health OS dashboard.